Trump is reading the GOP base wrong on the Affordable Care Act

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The only plausible explanation for President Trump’s renewed effort through the courts to do away with the Affordable Care Act, other than muscle memory, is a desire to play to his base despite widely reported misgivings in his own administration and among Republicans in Congress.

Reality check: But the Republican base has more complicated views about the ACA than the activists who show up at rallies and cheer when the president talks about repealing the law. The polling is clear: Republicans don’t like the ACA, but just like everyone else, they like its benefits and will not want to lose them.

The big picture: About three quarters of Republicans still have an unfavorable view of the ACA, and seven in 10 say repealing the law is a top health priority for Congress — higher than other priorities such as dealing with prescription drug costs. And yes, 7 in 10 Republicans still want to see the Supreme Court overturn the law.

But as the chart shows, majorities of Republicans like many elements of the ACA —especially closing the “donut hole” in Medicare prescription drug coverage (80%), eliminating copayments for preventive services (68%), keeping young adults under 26 on their parents’ plans (66%) and subsidies for low and middle-income households (63%).

  • Nearly half of Republicans want the Supreme Court to keep the protections for pre-existing conditions (49%), and even more show general support for the pre-existing conditions protections (58%).
  • During the repeal and replace debate in 2017, even Republicans were nervous to hear that these sorts of things would go away. The 2020 campaign would drive home to the public, and to Republicans, what they have to lose — and it would become especially real to them if the 5th Circuit Court of Appeals upholds the ruling striking down the ACA.

Maybe Republicans would forget about these lost benefits if they could agree on a replacement plan they liked? But there isn’t one, and many of the ideas thought to be elements of one — such as cutting and block granting both Medicaid and ACA subsidies — are non-starters with Democrats and moderate Republicans on Capitol Hill. They’re unpopular with the public, too. 

The bottom line: It is widely accepted that a renewed debate about repeal hands Democrats a powerful new political opportunity. Deeper in the polling, it’s also clear that’s it’s more of a mixed bag for Republicans than President Trump may realize.  

 

 

 

So, about being the “party of health care”

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GOP leaders are trying their best to put a lid on President Trump’s talk of a new and wonderful health care plan that would define the Republican Party for 2020.

“Not any longer,” Senate Majority Leader Mitch McConnell said yesterday when asked whether he and Trump differ on health care.

  • McConnell said he spoke to Trump Monday and “made it clear to him that we were not going to be doing that in the Senate.”
  • RNC Chair Ronna McDaniel and Trump campaign manager Brad Parscale also “tried to tell the president they could not understand what he was doing,” The New York Times reports.

Rhetorically, Trump has kicked the can past 2020, just after pushing his administration to dive back into — and escalate — the legal fight that hurt Republicans so badly in 2018.

  • “I wanted to delay it myself,” Trump said in the Oval Office yesterday, denying that McConnell forced his hand. “I want to put it after the election, because we don’t have the House.”

Reality check: It’s still the Justice Department’s position that the courts should strike down the Affordable Care Act. As long as this lawsuit is still active — and that will be a while — it’ll be accurate for Democrats to say on the campaign trail that Trump is trying to end protections for pre-existing conditions.

  • In the short term, Trump’s rhetorical punt to 2021 may dampen the intensity of questions about how Republicans would rebuild a new system for individual coverage — questions the party has struggled to answer for the past 9 years.
  • But in the end, the only good way out is for the Trump administration to lose this case.

 

 

 

The winning health care message will be about out of pocket costs

https://www.axios.com/winning-2020-health-care-out-of-pocket-costs-d5708e35-b308-4c91-a636-121e45f82032.html

Illustration of a wallet full of band-aids

As the 2020 campaign ramps up, Democrats may be able to rally their base by talking about universal coverage and making health care a right through Medicare-for-all. Republicans may be able to motivate their core voters by branding progressive Democratic ideas as socialism.

The catch: But it’s the candidates who can connect their plans and messages to voters’ worries about out of pocket costs who will reach beyond the activists in their base. And the candidates aren’t speaking to that much, at least so far.

By the numbers:

  • The anxiety over out of pocket costs is real. In a January 2017 Kaiser poll, 48 percent of voters worried about paying their health care bills.
  • People who are sick are especially concerned, with 66 percent worried and 49 percent very worried.
  • It isn’t just in their heads: a whopping half of people who are sick have a problem paying their medical bills over the course of a year. The health insurance system is not working for people who are sick.

Thanks in part to the Affordable Care Act, only 10 percent of the population remains uncovered. But that means many Americans are less focused on getting to universal coverage, even though candidate after candidate talks about it. They have insurance and are focused on their own, often crippling health care costs.

  • Most Americans are healthy and don’t use much care, but almost everyone, not just people with a major illness, worries about what might happen if they or a family member get cancer or heart disease or suffer a permanent injury.
  • That’s what fuels health care as an issue: the fear of facing costs people know they cannot afford. And that’s why protections for people with pre-existing conditions broke through as a prominent issue in the midterm election.
  • The debate and the Democratic message could shift back to the ACA again, after President Trump and the Justice Department’s surprise decision to push for throwing out the entire law in the courts. That move handed Democrats a political opportunity they will not ignore: a pre-existing conditions debate on steroids.

Recent trends have made problems with out of pocket costs worse:

Some of the administration’s policies are exacerbating the problem, such as their efforts to push cheaper short term insurance plans for the healthy, which drive up costs for the sick because they leave fewer healthy people in the regular insurance plans to help pay for sick people’s costs.

  • Several of the candidates’ plans address out of pocket costs, including the Bernie Sanders plan, which eliminates them. Their advocates just don’t talk about it much.

The bottom line: It’s hard to see the new debate about the health system breaking out of familiar boxes unless the messaging changes. And when the general election comes, both parties will have to convince voters that they will do something about out of pocket costs if they want to reach beyond core base voters. 

 

 

 

DOJ supports striking entire ACA: 5 things to know

https://www.beckershospitalreview.com/legal-regulatory-issues/doj-supports-striking-entire-aca-5-things-to-know.html

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In a March 25 court filing, the Department of Justice said it supports a judge’s ruling that the entire Affordable Care Act should be invalidated, according to CNN.

Five things to know:

1. In December, a federal judge in Texas held that the ACA is unconstitutional. He sided with the Republican-led states that brought the lawsuit, Texas v. United States, calling for the entire ACA to be struck down because Congress eliminated the healthcare law’s individual insurance mandate penalty.

2. The case is now pending in the 5th Circuit Court of Appeals. In a filing with the appellate court on March 25, the Justice Department said it supports the federal judge’s ruling that invalidated the ACA.

3. “The Department of Justice has determined that the district court’s judgment should be affirmed,” lawyers for the Justice Department wrote to the 5th Circuit Court of Appeals, according to Politico. “[T]he United States is not urging that any portion of the district court’s judgment be reversed.”

4. The filing signals a major shift in the Justice Department’s position. When Jeff Sessions was attorney general, the administration argued only certain parts of the ACA, like protections for people with pre-existing conditions, should be struck down, but the rest of the law could stand, according to CNN.

5. A coalition of Democratic-led states is challenging the Texas ruling. Regardless of the outcome, the 5th Circuit’s ruling is likely to be appealed to the Supreme Court, according to Politico.

Access the full CNN article here.

Access the full Politico article here.

 

 

Trump admin now backs elimination of ACA in court

https://www.healthcaredive.com/news/trump-admin-now-backs-elimination-of-aca-in-court/551319/

UPDATED: AHA blasted the decision, calling it “unprecedented and unsupported” by law or facts and warned it would lead to repeal of Medicaid expansion and gut protections for those with pre-existing conditions.

Dive Brief:

  • The Trump administration has reversed its stance on the Affordable Care Act, arguing in a court filing Monday that the entire law should be eliminated instead of just removing provisions protecting people with preexisting conditions.
  • The move came hours after Democratic attorneys general defending the ACA filed their brief arguing that the landmark law is still constitutional even without an effective individual mandate penalty. Both filings are in the Fifth Circuit following an appeal of a Texas judge’s decision from December declaring the law unconstitutional after Congress set the mandate penalty to zero in tax overhaul legislation. That decision was stayed pending appeal.
  • Industry groups lambasted the administration’s about-face. America’s Health Insurance Plans CEO Matt Eyles said in a statement the decision was, like the Texas ruling, “misguided and wrong.” He added the payer lobby “will continue to engage on this issue as it continues through the appeals process so we can support and strengthen affordable coverage for every American.” Federation of American Hospitals CEO Chip Kahn said in a statement the decision is “unfortunate but not unexpected considering [the administration’s] long-held views on the health law.”

Dive Insight:

Elimination of the ACA would be a particular blow for some payers that have found increasing profitability in the individual market. Centene and Molina have found success with the exchanges and have expanded their footprints.

It would also put major hospital chains in a bad spot. Companies like HCA, Tenet and Community Health Systems have exposure that could subject them to reduced patient volumes and more bad debt, Leerink analyst Ana Gupte said when the Texas ruling first came down.

Public support for the ACA has gradually increased over the years, and the latest polling from the Kaiser Family Foundation shows about 53% of respondents giving a favorable view and 40% unfavorable. Individual components of the law are even more popular.

The ACA, which just days ago marked its ninth anniversary, brought forth massive change in American healthcare. A repeal of the law would do the same, stripping insurance coverage for as many as 17 million people.

The Trump administration’s new stance presents an intensely stark contrast with the growing field of Democratic presidential contenders, who have shifted the healthcare conversation to the left as the 2020 field shapes up. Candidates have proposed various forms of Medicare for all as well as scaled back versions that still greatly expand government coverage.

It moves the DOJ away from even some Republicans. During last year’s midterms a few GOP candidates said they approved of the ACA’s most popular element — protection for people with preexisting conditions (although voting records didn’t necessarily back them up).

Most Democrats in Congress aren’t fully backing any single-payer model at the moment, but their support for the ACA is strong. Democrats in the House of Representatives are expected to announce a legislative package Tuesday that would strengthen the ACA by eliminating short-term health plans that don’t comply with the law and increasing subsidies for exchange plans.

Since the GOP’s quite public failure to repeal the law two years ago, efforts to do so through Congress have sputtered to nearly a halt. Instead, the Trump administration started chipping away at the law’s provisions. It cut the open enrollment period for ACA plans, as well as the advertising budget for promoting sign-ups, and stopped cost-sharing reduction payments to insurers.

More recently, HHS has bolstered short-term and association health plans that offer cheap but skimpy coverage not in line with ACA requirements. Analysts fear proliferation of these plans could draw young and healthy people away from the exchanges, jeopardizing the stability of the risk pool.

A Democratic-led House panel launched an investigation into short-term plans and is requesting documents from Anthem and UnitedHealth Group, among other companies.

The legal issue at hand is known as severability — the question of whether a single provision of the law, in this case the individual mandate, becoming unenforceable invalidates the entire statute. The mandate was also the key question in the original U.S. Supreme Court ruling allowing the ACA to move forward.

The high court has since lurched to the right, which is notable if the appeal on the Texas ruling reaches that stage, although that would likely be far down the road.

 

 

 

Judge rules Trump AHP expansion unlawful ‘end-run’ around ACA

https://www.healthcaredive.com/news/judge-rules-trump-ahp-expansion-unlawful-end-run-around-aca/551601/

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Dive Brief:

  • A federal judge on Thursday struck down a Trump administration expansion of association health plans, which aren’t bound by the requirements of the Affordable Care Act. U.S. District Judge John Bates said the June rule from the Department of Labor that loosened restrictions on what groups could band together to offer AHPs “is clearly an end-run around the ACA.”
  • The ruling stems from a lawsuit 11 states and the District of Columbia filed to challenge the DOL rule. It comes the same week the Trump administration stepped up its attacks against the ACA, arguing in a court filing Monday the law should be eliminated in its entirety following a Texas judge’s decision the act is unconstitutional without the individual mandate penalty.
  • The judge had strong language condemning the administration’s attempt to allow for easier creation and use of AHPs, calling the regulatory change a “magic trick” that allowed for “absurd results” undermining the intent of Congress.

Dive Insight:

The ruling is a blow to the Trump administration’s efforts to circumvent the ACA, which ramped up significantly with the administration’s filing this week seeking complete repeal of the law. Another hit to those efforts came down Wednesday when a different federal judge struck down Medicaid work requirements in Arkansas and Kentucky.

The renewed fight comes as Democrats lining up for a 2020 presidential run are pushing for more progressive policies than have previously gained public traction. Some Democratic contenders are making Medicare for all and other single-payer models a central part of their platforms as healthcare shapes up to be a major issue for the next presidential election.

Experts have argued extended use of AHPs could siphon away young and healthy people looking for minimum coverage at a lower cost. If they choose AHPs they upset the balance on risk pools for more comprehensive coverage. Also, many consumers don’t understand the tradeoff and could be surprised by what isn’t covered when they are in need.

But even though the plans aren’t required to meet ACA standards, some that have formed have been adamant they provide adequate coverage, including the 10 essential ACA benefits. The plans are less obstructive to the regulatory environment than short-term health plans, which have also been granted more leeway under the Trump administration.

Land O’Lakes, for example, which said it was the first to offer an AHP under the more relaxed rules, said its plan covered essential benefits and pre-existing conditions, as well as “broad network coverage.”

The Society of Actuaries has said as many as 10% of people in ACA plans could leave for AHPs, which would also drive up premiums for plans in the individual market. Avalere predicted about 3.2 million people would shift and premiums would rise by 3.5%.

Supporters of AHPs decried the judge’s decision Thursday. Kev Coleman, founder of AssocationHealthPlans.com, said in a statement the ruling will hurt small businesses throughout the country.

“Thousands of employees and family members within the small business community have already enrolled in association health plans — which help lower health care costs — since they first became available last fall,” he said. “They have provided a means by which broad benefits may be accessed at more economical prices. While I do not believe today’s ruling will survive appeal, I believe Judge Bates’ decision is an unnecessary detour on small businesses’ path toward more affordable health coverage.”

 

 

Trump’s all-or-nothing gamble

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The Trump administration’s new legal argument against the Affordable Care Act is a political risk. It may also be a liability in court.

How it works: The legal issue here is “severability” — if the ACA’s individual mandate is unconstitutional, can it be struck down in isolation? Or is it too intertwined with other parts of the law?

Flashback: We’ve seen this movie before — in 2012, at the Supreme Court.

  • According to behind-the-scenes reporting from the 2012 ACA case, four conservative justices wanted to strike down the entire law. Chief Justice John Roberts reportedly wanted to strike down the mandate and protections for pre-existing conditions while leaving the rest intact.
  • But the other conservatives wouldn’t budge, and faced with a choice between upholding or striking down the whole thing, Roberts chose the former.

The Justice Department has now forced that same all-or-nothing decision into the case now pending before the 5th Circuit Court of Appeals.

“There’s no way they were getting Roberts’ vote anyway … but this won’t help,” said Jonathan Adler, a law professor at Case Western Reserve University who helped spearhead a different challenge to the ACA.

  • “It’s contrary to everything he’s ever said and done on severability,” Adler argues.

It may not get that far. “I think the states ultimately lose,” Adler said. “I think the most likely outcome is they lose in the 5th Circuit. If they don’t lose at the 5th Circuit, they will lose at the Supreme Court.”

If that’s what happens, adopting this riskier legal strategy may ultimately be the only thing that saves Republicans from the political nightmare of wiping out 20 million people’s health care coverage with no strategy on how to replace it.

  • I’ll spare you a long list of quotes from President Trump’s trip to Capitol Hill yesterday. Suffice it to say that no, Republicans still do not have a plan for what happens next if they finally succeed in killing the ACA. Some things never change.